BANK NEGARA MALAYSIA

APPLICATION FORM FOR MONEY SERVICE BUSINESS LICENCE

To:
Director
Money Services Business Regulation Department
Bank Negara Malaysia
Jalan Dato Onn
50480 Kuala Lumpur

Part 1: Type of licence applied for

Please tick () where applicable

Class A licence: To carry on money changing and remittance business

Class B licence: To carry on remittance business only
Class C licence: To carry on money changing business only
Class D licence: To carry on wholesale currency business only

Part 2: Applicants particulars

(a) Background

Name of company Telephone no.

BRIC no. Fax no.

Date of incorporation Email address

Name of contact person

Business address

Business registered Document to be enclosed:

Please tick () if enclosed together
address with the form
(if address belongs to company
1. Certified true copy of Form 9
secretary of the applicant,
issued by Companies
please state the name,
Commission of Malaysia
telephone and fax number of
secretary company)
2. Certified true copy of the
companys M&A

(b) Proposed shareholders and shareholding structure

If space provided is insufficient , please provide in a separate sheet

Name NRIC/passport/ Nationality Amount of Percentage of

(may be an individual or company) BRIC number shareholding (RM) shareholding
1.

2.

3.

4.

5.

Total

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(c) Proposed Board of Directors, Chief Executive Officer (CEO) or key responsible person for day-
today management of the company
If space provided is insufficient , please provide in separate sheet

Name NRIC/passport Nationality Designation/resposibility

number e.g. Non-executive director, Managing director,
CEO, Manager etc

1.

2.

3.

4.

5.

(d) Corporate structure

Applicable if applicant is part of group of companies

Please furnish the corporate structure of applicant i.e. parent/sister company and explain in brief of business
activities of each related companies in separate sheet of paper

(e) Business plan

Please furnish business plan on separate sheet of paper. Business plan of applicant should contain, among
others:

1. Proposed location of business (full address is not required);

2. Feasibility studies on business model, potential customer, projected growth and income for the next three
years including cash flow, source of funds for business operation; and

3. Proposed governance arrangements, internal controls and risk management framework to manage the
business operations.

Please refer to Money Services Business (Licensing) Regulation 2012 for further information (available at the
Banks website)

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Part 3: Declaration on the information provided and consent for disclosure of information
1. The company confirms that all the information given in this document and the documents submitted are
true, and understands that if the company furnishes any information required which is false, inaccurate,
misleading or contains material errors or omissions, the licence may not be granted by Bank Negara
Malaysia (Bank). In the event that the licence has been granted, it may be revoked;

2. The company applies for a licence to carry on Money Services Business under section 5 of the Money
Services Business Act 2011 based on information provided with this application and any additional
information provided to the Bank in the course of the application; and

3. The company will promptly notify the Bank in writing of any changes in the information the company has
provided and supply any other relevant information which may come to light in the period during which its
application is being considered by the Bank. The company acknowledges that the Bank may disclose any
information provided in the performance of its statutory functions or otherwise as may be specifically
authorised by law.

I, as a person who is authorised signatory of ____________________________ (name of company) and

responsible for the management of the company:

(a) Make this solemn declaration conscientiously believing the same to be true, and by virtue of the
provisions of the Statutory Declarations Act 1960; and

(b) As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services
Act 2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial
Services Act 2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002
(DFIA),I hereby authorize any licensed business under FSA and IFSA and prescribed institutions under
DFIA where the applicant maintains its accounts, or has financial liabilities, to disclose to Bank Negara
Malaysia, any information relating to the companys accounts and affairs including financial liabilities
for the purpose of processing this application.

___________ ______________________ ________________________ __________________

(Date) (Signature) (Name in capital letter) (Designation)

This declaration was made before me:

______________________________
(Signature of Session Court Judge, Magistrate or Commissioner For Oaths)

Date:

Note:
Please do not enclose any payment for licence fee with the application. Licence fee is payable upon the approval of application. Applicant
will be informed in writing of the Banks decision on the application.

Part 4: Form to be completed by each director/shareholder/CEO/or key responsible person of the

company applying for the money services business licence Page 3/7
 (Please make copies of Part 4 for each individual)

(a) Designation of key responsible person

Please tick () where applicable. Tick more than one box if you hold more than one position
Please attach latest
Director passport sized
Shareholder photograph here

Chief Executive Officer*

* Or whatever name i.e. general manager/manager who is responsible for the conduct of business and
the day-to-day management

(b) Particulars
If the shareholder is a company/corporation, please complete relevant items in Part 4(b)

Name Document to be enclosed:

Please tick () if enclosed together
with the form
Gender (not applicable for a 1. For individual - Certified true copy
company) of NRIC/passport and insolvency
NRIC/Passport/BRIC no. report (local/foreign)
2. For company:
(whichever applicable) - Certified true copy of Form 9
Nationality (not applicable for a issued by Companies
company) Commission of Malaysia (on
Current address company registration); and
- Certified true copy of the
(for company, please state the name
companys memorandum and
of contact person)
association

Telephone no. (home/office) Fax no.

Telephone no. (mobile) Email

address
(c) Working experience (for the last 5 years)
(for individual)

Position/designation Organisation/company Business activity Duration of service

(year to year)
1.

2.

3.

4.

5.

(d) Educational background

(for individual)

Highest level Institution Year obtained

1.

2.

3.

4.

5.

(e) Details of other business owned or interest owned in other business (including money services
business) (please provide additional sheet if space provided is inadequate)
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 Name of business Business activity Type of interest Amount and percentage
(e.g. shareholder, director, partner of shareholding owned
etc)
in other business

1.

2.

3.

4.

5.

(f) Are any of your family members (parents, siblings, spouse and children) having interest in any
money services business? If yes, please fill the following

Name of family Relationship with you Name of money services Type of interest
member business (e.g. shareholder, director,
partner etc)
1.

2.

3.

4.

5.

(g) Statutory Declaration

I, _________________ (name of applicant), of NRIC / Passport No. ____________________ do solemnly and

sincerely declare that:

A: I am not subject to the disqualifications mentioned below:

(i) I have not been convicted of an offence under the repealed Money Changing Act 1998 [Act 577], the
Money Services Business Act 2011 [Act 731], the repealed Payment Systems Act 2003 [Act 627], the
repealed Banking and Financial Institutions Act 1989 [Act 372], the repealed Insurance Act 1996 [Act
553], the repealed Islamic Banking Act 1983 [Act 276], the repealed Takaful Act 1984 [Act 312], the
repealed Exchange Control Act 1953 [Act 17], the Financial Services Act 2013 [Act 758], the Islamic
Financial Services Act 2013 [Act 759], the Central Bank of Malaysia Act 2009 [ Act 701], the
Development Financial Institutions Act 2002 [Act 618], the Anti-Money Laundering and Anti-Terrorism
Financing Act 2001 [Act 613], the Capital Markets and Services Act 2007 [Act 671] or the Companies
Act 1965 [Act 125];

(ii) I have not been convicted of a criminal offence relating to dishonesty or fraud under any written law
within or outside Malaysia;

(iii) If I have been convicted of a criminal offence not relating to dishonesty or fraud under any written law
within or outside Malaysia, a period of five years has lapsed since the completion of my sentence*;

(iv) I am not an undischarged bankrupt;

(v) I have not suspended payments or compounded with my creditor whether in or outside Malaysia;

(vi) (a) I have not been issued with an order of detention, supervision, restricted residence, banishment
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 or deportation; or
(b) I have not been imposed with any form of restriction or supervision by bond or otherwise,
under any law relating to prevention of crime, preventive detention for prevention of crime or drug
trafficking, restricted residence, banishment or immigration;

(vii) I have not held the position of a director or been directly concerned in the management of any
company which has been convicted of an offence under any written law designed to protect members
of the public against financial loss due to dishonesty, incompetence or malpractice during the tenure
of my office;

(viii) I am a person of probity, personal integrity and good reputation;

(ix) I possess the appropriate skills, experience and have sufficient knowledge of the Money Services
Business Act 2011 and the relevant provisions in the Anti-Money Laundering and Terrorism Financing
Act 2001 to effectively fulfil the role and responsibilities of the position;

(x) I have managed my affairs properly and prudently; and

(xi) If I am to be appointed as a chief executive officer or to be primarily responsible for the day-to-day
management of the company, I will be available for full time employment.

B: I am*:
(i) representing the interest of __________________; or
(ii) not representing the interests of any person;

C: All the information submitted above is true.

This declaration was made before me:

(Signature of Sessions Court Judge, Magistrate or Commissioner For Oaths)

Date:

Part 5: Consent for Disclosure of Information

Delete whichever not applicable/relevant
Page 6/7
Please complete where applicable:

1. For individual who has completed Part 4 of this form.

As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services Act
2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial Services Act
2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002 (DFIA),I hereby
authorize any licensed business under FSA and IFSA and prescribed institutions under DFIA where the
applicant maintains its accounts, or has financial liabilities, to disclose to Bank Negara Malaysia, any
information relating to the companys accounts and affairs including financial liabilities for the purpose of
processing this application.

______________ _________________ _____________________ __________________

(Date) (Signature) (Name in capital letter) (Designation)

2. For a company (corporate shareholder) which has completed Part 4 of this form.

As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services Act
2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial Services Act
2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002 (DFIA), I on behalf of
the company (as a shareholder) hereby authorize any licensed business under FSA and IFSA and
prescribed institutions under DFIA where the applicant maintains its accounts, or has financial liabilities, to
disclose to Bank Negara Malaysia, any information relating to the companys accounts and affairs including
financial liabilities for the purpose of processing this application.

[Consent should be given by the director/CEO who is responsible of the management of the company].

_____________ _________________ _____________________ __________________

(Date) (Signature) (Name in capital letter) (Designation)

IMPORTANT:

BANK NEGARA MALAYSIA MAY REQUEST FOR ADDITIONAL INFORMATION AS AND

WHEN REQUIRED

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